What is the management approach for elevated liver enzymes during pregnancy?

Management of Elevated Liver Enzymes in Pregnancy

The management of elevated liver enzymes during pregnancy requires prompt identification of the underlying cause, with treatment focused on reducing maternal and fetal morbidity and mortality through condition-specific interventions. 1

Initial Assessment

• Measure serum bile acids, transaminases, bilirubin, alkaline phosphatase, GGT, and platelets in the initial evaluation of elevated liver enzymes 1
• Evaluate for symptoms of liver disease, including pruritus, right upper quadrant pain, and jaundice 1
• Consider normal physiological changes of pregnancy that can mimic liver disease, including hyperdynamic circulation, palmar erythema, and spider naevi 2
• Be aware that normal ranges for serum biochemistry and hematological parameters may alter during pregnancy 2

Diagnostic Categories

Pregnancy-Specific Liver Disorders

1. Preeclampsia and HELLP Syndrome

   • Control severe hypertension with labetalol, nifedipine, or methyldopa; intravenous therapy may be required 2
   • Administer magnesium sulfate to prevent eclamptic seizures in women with severe hypertension 2
   • Deliver promptly once maternal coagulopathy and severe hypertension are corrected 2, 1
   • Do not use corticosteroids to improve maternal outcomes in HELLP syndrome 2
   • Perform abdominal ultrasound if symptoms suggest hepatic hematoma 2
   • Consider early referral to a transplant center if signs of hepatic failure develop 2

2. Acute Fatty Liver of Pregnancy (AFLP)

   • Consider intensive care admission for women with encephalopathy, elevated serum lactate, or high Swansea criteria score 2
   • Expedite delivery once coagulopathy and metabolic derangements are treated 2, 1
   • Consider plasma exchange post-delivery for severe hepatic impairment 2
   • N-acetylcysteine may be considered for women requiring intensive care 2
   • Early referral to a transplant center for severe hepatic impairment 2

3. Hyperemesis Gravidarum

   • Measure liver tests as they are elevated in 40-50% of severe cases 2
   • Screen for primary liver disease if markedly raised liver tests 2
   • Consider anti-emetic treatment with first-line options including cyclizine, doxylamine/pyridoxine, prochlorperazine, or promethazine 2

4. Intrahepatic Cholestasis of Pregnancy (ICP)

   • Test for serum bile acid concentrations to identify pregnancies at risk 2
   • Measure serum bile acids at least weekly from 32 weeks' gestation 2
   • Offer ursodeoxycholic acid (UDCA) for maternal pruritus and to reduce risk of spontaneous preterm birth 2, 1
   • Consider additional therapies for pruritus (rifampicin, cholestyramine, guar gum, activated charcoal) 2
   • Recommend delivery from 35 weeks' gestation for women with bile acids >100 μmol/L due to increased stillbirth risk 2, 1
   • Ensure liver function tests return to normal within 3 months post-delivery 2, 1

Pre-existing or Coincidental Liver Disease

• Optimize health and disease management prior to pregnancy when possible 2
• Continue most medications used for chronic liver disease management as stopping could cause clinical deterioration 2
• Consider viral hepatitis and gallstones as common coincidental liver diseases during pregnancy 3, 4

Management Principles

• Investigations including ultrasound, MRI, ERCP, endoscopy, and liver biopsy may be performed when benefits outweigh risks 2
• Multidisciplinary approach involving hepatologists, obstetricians, and maternal-fetal medicine specialists 1
• Post-delivery monitoring to ensure normalization of liver function tests 1

Common Pitfalls and Caveats

• Up to 30-40% of elevated liver enzyme cases during pregnancy have unclear etiology 3
• Delayed diagnosis and treatment can adversely affect maternal and fetal outcomes 5
• Liver dysfunction may be the first presentation of an underlying chronic liver disease 6
• Physiological changes of pregnancy may mask or mimic liver disease 6

Follow-up

• Monitor liver function tests until normalization post-delivery 2
• Investigate for underlying liver disease if liver function tests remain abnormal 3 months after delivery 1
• Consider genetic screening if there is family history of hepatobiliary disease, early onset, or severe disease 2